PSEUDOCYST OF PANCREAS

PSEUDOCYST OF PANCREASPEOF.DR.M.S.ELANGOVAN M.S,UNITPresented by Dr.saravanan m.s,(p.g)

CASE SUMMARY42 yr old male presented with complaints of abdominal pain for 20 days more over epigastric to left hypochondriumH/o vomiting No h/o abdominal distension,fever,hematemesis,melena,trauma, constipationNo h/o urinary symptomsNo h/o loss of wt/appetite

PAST AND PERSONAL HISTORYH/o abdominal pain for the past 6 months on and off was diagnosed as a case of pancreatitis and treatedNo h/o previous surgeries,jaundiceNot a known DM,HT,ASTHMA,TB,CAHD,EPILEPTICKnown alcoholic past 20 years Smoker for 20 years

ON EXAMINATIONConscious,oriented,afebrile,no pallor,not icteric,no clubbing,no cyanosis,no pedal edemaCVS-S1S2 +RS-bilateral air entry +CNS-No focal neurological deficit

P/AINSPECTION Not distented,umblicus in midline,all quadarents equally moves with respiration,skin normal, no vip,vgp,hernial orifices free,ext genitalia normal,supra clavicular fossa free

PALPATION Soft,not warm,mild tenderness present over epigastric and left hypochondrium, VAGUE MASS PALPABLE over epigastric,left hypochondrium of size 8*8 cm No guarding,no rigidity

P/APERCUSSION No shifting dullnessAUSCULTATION BS +

INVESTIGATIONSCBC Hb 10.6 gm%,Tc 5800,DC p63% L33% E 04% RBC 3.4 million cumm,platelet 4.7 lakh pcv 31%BT 1 minute CT 2 min 30 secRBS 95 mg/dlUrea 32 mg/dlSr creatinine 1.0 mg/dl

INVESTIGATIONSLFT SGOT 24u/l SGPT 20u/l Sr bilirubin total 0.8mg conjugated 0.3mg% un conjucated 0.5mg% Sr.ALP 49u/l,Sr protein 6.5 gm%

INVESTIGATIONSUGI scopy Esophagus,stomach,duodenum normalUSG abdomen Pancreas large cyst present in panceatic region other organs normal

INVESTIGATIONSCT abdomen Cystic structure noted along the head and tail of pancreas with multiple parenchymal calcification Cyst from tail exends along the oesophageal hiatus Cyst noted in the lesser sac extends along the entire lt flank measuring 20 cc in the craniocaudal direction IMP; Chronic pancreatitis with multiple pseudocyst one extends along the oesophageal hiatus noted in the post mediastinum

DIAGNOSISPseudocyst of pancreas extends to mediastinum

TREATMENTNPOIVFAntobioticsAnelgesicsInj.octeriotide 100mic sc bd

Pre operative instructionsConsentNPO since 2 pm Inj TT 0.5cc imInj Lignocaine test doseParts preparationBowl preparation stomach wash at 10 pm&2amEnema 9 pm & 4 Am

TreatmentProcedure Laprotomy and Roux en y cystojejunostomy under epidural anesthesiaFindings 2 cyst of size15*12 & 10*8 cm communicating each other,attached with omentum

PROCEDURE pseudo cyst

Separation of sac from omental attachme nt

aspiration

Drainage of fluid (1.6 litre)

PROCEDURE jejunum resected 20 cm from dj flexure

Proximal and distal end of jejunum

Closure of distal end of jejunum

Cysto jejunostomy

Cysto jejunostomy

Cysto jejunostomy

Jejeno jejunostomy (end to side anastomosis)

Jejeno jejunostomy

Jejeno jejunostomy

Roux en y cystojejunostomy

Post operative treatmentNPOIO,BP,TPR chart,IVFAntibioticsAnalgesics

Fluid analysisCulture no growthLipase 236u/lStaining GPC,GPB,GNB,GNC,AFB Negative pus cells nilCytology Scattered lymphocytes,occasional reactive mesothelial cells admixed with macrophages in a proteinacious background,no evidence of malignancy.

DiscussionDefinition collection of amylase rich fluid in a wall of fibrous or granulation tissueEtiology Following attack of 1)acute pancreatitis 2)chronic pancreatitis 3)pancreatic trauma

SITESLesser sacIn relation to Duodenum Jejunum Colon Splnic hilum

TypesDuration Acute ChronicCommunication with main pancreatic duct Communicating NoncommunicatingNumber Single pseudocyst 85% Multiple pseudocyst

Degidio classificationTypesOccurrenceCommunication with ductType 1After attack of acute pancreatitisNormal duct anatomyNo fistulaTYPE 2Acute on Chronic pancreatitisAbnormal duct anatomy with out sriture50% chances of fistulaType 3Chronic pancreatitisAbnormal duct anatomy with sritureAlways communicating

Differential diagnosisPancreatic abscessCystic adenocarcinomaCyst in liverMesentric cystHydatid cystAortic aneurism

Indications for surgerySize of more than 6 cmInfected pseudocystPersisting painPressure effects

Complecations of cystProcessOutcomesInfectionAbscessSystemic abscessRupture into the gut into the peritoniumGI bleeding,fistulaperitonitisEnlargements pressure effects painObstructive jaundice,bowl obstructonErosion into a vesselHaemorrage into the cysthaemoperitoneum

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